Home Health & Hospice Week

HHAs and MedPAC actually agree on something.

If Medicare wants to increase home care quality with Value-Based Purchasing, its proposed model isn’t up to the job. So said many commenters on the 2016 HH Prospective Payment System proposed rule.

Recap: Industry commenters on the proposed rule had lots to say about the Value-Based Purchasing model the Centers for Medicare & Medicaid Services laid out in the proposed rule published in the July 10 Federal Register (see Eli’s HCW, Vol. XXIV, No. 24). Under VBP, all home health agencies in nine pilot states (Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee) will be subject to the program starting Jan. 1. CMS will “adjust” up to 5 percent of those agencies’ Medicare reimbursement for 2016 and 2017 outcomes; up to 6 percent for 2018; and up to 8 percent for 2019 and 2020. The adjustments based on 2016 outcomes would take effect in 2018 and so forth. CMS will calculate VBP scores based on 29 quality measures —15 current outcome measures, 10 current process measures, and four new process/reporting measures (see box, p. 277).

For once, HHA commenters and the Medicare Payment Advisory Commission agreed on one criticism of the VBP program — there are just way too many measures involved.

“The proposed model includes too many quality measures, diluting (VBP’s) focus and increasing the burden of operation,” MedPAC said in its comment letter.

“CMS is trying to include too many measures and should concentrate on those ‘proven measures’ that truly support the concept of having a ‘high impact on care delivery ... to improve health outcomes ... and experience of care for patients,’” said Corrie Hall with Alacare Home Health & Hospice in Alabama.

“We are extremely concerned about the administrative and cost burdens imposed by the sheer number (29) of proposed HHVBP quality metrics,” said UnityPoint at Home in the VBP pilot state of Iowa. “If all proposed 29 quality and patient satisfaction measures are retained, the impact on our current Performance Improvement/Process Improvement process would generate the need for additional resources coupled with across-the-board reductions in reimbursement,” says the health system with 13 home care locations in the state.

“Agencies need to be able to focus on taking care of the patients and not on so many outcome measures,” stressed one HHA in the VBP state of Tennessee.

“Suddenly we will be going from 10 measures” used to calculate an agency’s star rating on Home Health Compare “to a total of 29,” said Michelle Garges in the pilot state of Florida. That’s “a significant jump ... an unrealistic jump and an unnecessary jump,” Garges criticized in her comment letter.

“The sheer volume of metrics offered in the proposal are too numerous to be implemented by a reasonable agency and to yield valid data supporting their power as predictors of effective care,” contended Margaret Franckhauser, CEO of Central New Hampshire VNA & Hospice, in her letter.

The National Association for Home Care & Hospice is “concerned that the proposed measures create an overly complex program,” NAHC said in its comment letter. “The measures should be limited to a select set that are most meaningful for patients and best reflect quality home health care. In addition, fewer measures would allow agencies to better focus on areas that impact quality of care within their agency.”

Unintended consequence: “Because all measures are weighted equally, logic for purposes of the value-based purchasing program dictates focusing efforts on the measures for which the agency receives the lowest scores,” noted the Visiting Nurse Associations of America in its comment letter. “However, are all measures equally important for improving quality? CMS could better direct agencies’ efforts by reducing the total number of measures used in the program.”

Commenters Knock Process Measures

Many commenters asked CMS to slim down the list. For example, the Nebraska Hospital Association “urges CMS to reduce the number of measures in the HH VBP program and ensure the program measure set is focused on the highest priority areas for improvement,” said the trade group from the VBP pilot state.

But commenters were less united on how to achieve the goal of reducing the number of measures. Some providers wanted to keep only clinical measures and toss any process measures. “The focus should be on using outcome measures rather than process measures,” Alacare’s Hall said. “If an agency is using the process measures effectively, then this should show up in results of the appropriate outcome measures.”

“The use of process measures should be eliminated and only outcome measures utilized,” said physical therapist John M. DiCapo from Illinois in his commenter letter. “Process measures only show if a person is provided specific care but do not take into account the quality of care provided. We should not care if someone says they provided care, we should judge them on the outcomes of their care.”

On the other hand: The Medicare Payment Advisory Commission “prefers clinical outcome measures over process measures,” the advisory body to Congress said in its letter. But “we do recognize the importance of ensuring … that all health care personnel are immunized annually against influenza.”

Dump 4 New Measures, Providers Urge

Many commenters agreed that the four new measures CMS wants agencies to report via a new web portal should be first on the list to be scrapped. “CMS should not require new measure submission until they have been validated, tested, and [National Quality Forum]-endorsed for the home health setting,” said Premier Healthcare Alliance. “Testing and validation may elucidate data collection issues that hinder some HHAs from submitting measures. Accordingly, it is inappropriate to hold HHAs accountable for data submission until field testing has proven that data collection is feasible.”

An alternative: “We would support CMS incentivizing voluntary submission of measures to support continued measure development,” Premier offered. CMS proposed a similar mechanism under the Comprehensive Care for Joint Replacement proposed rule. “CMS could award additional total performance score points for HHAs that choose to voluntarily report new measures.”

Workload: “Administrative burdens associated with a new reporting stream for this limited measure set would appear to outweigh its benefit,” said UnityPoint at Home in Iowa, a VBP pilot state. “Any additional measures should be incorporated within current mechanisms,” said the health system.

At the very least, CMS should phase in the four new measures, as well as the four not currently reported on Home Health Compare, said Kindred at Home (which acquired Gentiva this year) in its comment letter. “Kindred at Home thinks it’s important that HHA agencies have at least a year’s worth of experience collecting quality data, before they are held accountable for their performance on this data,” the chain said. “Delaying the implementation of these eight quality metrics will minimize the additional burden on providers, by focusing the initial quality reporting on measures tracked and readily available to home health agencies. These eight measures will require new processes to extract the data at the agency level and will create additional administrative burden within the agencies including the potential designation of a data-entry person.”

Agencies and their representatives also listed a variety of individual measures they had problems with (see story, this page).

Stay tuned: See whether CMS heeds commenters’ feedback in the final rule, which is expected out within a month or so.

Note: See the proposed rule at www.gpo.gov/fdsys/pkg/FR-2015-07-10/pdf/2015-16790.pdf.